Alexandria City Public Schools
Vision Care
Services
In-Network
Member Cost
Out-of-Network
Reimbursement
Exam With Dilation as Necessary
$0 Copay
Up to $30
_____________________________
More,
for less...
40%
OFF
Complete pair
of prescription
eyeglasses
20%
20%
OFF
Non-prescription
sunglasses
OFF
Remaining balance
beyond plan coverage
These discounts are for
in-network providers only
Hello,
Neighbor
• You’re on the INSIGHT
Network
_________________________________________
_________________
Contact Lens Fit and Follow-Up (Contact lens fit and two follow up visits are available once a comprehensive eye exam has been completed)
Standard Contact Lens Fit & Follow-Up
Premium Contact Lens Fit & Follow-Up
Up to $55
10% off retail
N/A
N/A
Retinal Imaging
Up to $39
N/A
Frames
$0 Copay; $150 allowance; 80% of charge over $150
Up to $75
Standard Plastic Lenses
Single Vision
Bifocal
Trifocal
Standard Progressive Lens
Premium Progressive Lens
Tier 1
Tier 2
Tier 3
Tier 4
$15 Copay
$15 Copay
$15 Copay
$80
$100 - $125
$100
$110
$125
$80, 80% of charge less $120 Allowance
Up to $25
Up to $40
Up to $55
Up to $40
Up to $40
Up to $40
Up to $40
Up to $40
Lens Options (paid by the member and added to the base price of the lens)
UV Treatment
$15
Tint (Solid and Gradient)
$15
Standard Plastic Scratch Coating
$0
Standard Polycarbonate
$40
Standard Polycarbonate - Kids under 19
$0
Standard Anti-Reflective Coating
$45
Premium Anti-Reflective Coating
$57 - $68
Tier 1
$57
Tier 2
$68
Tier 3
80% of charge
Photochromic/Transitions
$75
Polarized
20% off retail price
Other Add-Ons and Services
20% off retail price
N/A
N/A
Up to $5
N/A
Up to $5
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Contact Lenses
Conventional
Disposable
Medically Necessary
$0 Copay; $150 allowance; 85% of charge over $150
$0 Copay; $150 allowance; plus balance over $150
$0 copay, Paid in Full
Up to $120
Up to $120
Up to $200
Laser Vision Correction
Lasik or PRK from U.S. Laser Network
15% off the retail price or 5% off the promotional price
N/A
Frequency
Examination
Lenses or Contact Lenses
Frame
Once every 12 months
Once every 12 months
Once every 12 months
• For a complete list of
providers near you, use
our Provider Locator on
www.eyemed.com and
choose the INSIGHT
network or call
1-866-804-0982.
• For Lasik providers, call
1-877-5LASER6 or
visit eyemedlasik.com.
Premium progressives and premium anti-reflective designations are subject to annual review by EyeMed’s Medical Director and are subject to change based on market
conditions. Fixed pricing is reflective of brands at the listed product level . All providers are not required to carry all brands at all levels.
What’s in it for me?
Options. It’s simple really. We love our members—that’s why we are dedicated to helping you
see clearly and we’ve built a network that gives you lots of choices and flexibility. You can
choose from independent doctors and retail providers to find the one that best fits your needs
and schedule. No matter which one you choose, our plan is designed to be easy to use and to
save you money. Welcome to EyeMed.
eyemed.com
Benefits Snapshot
With Us
Out-of-Network
Reimbursement
Exam with dilation as necessary (Once every 12 months)
$0 Copay
Up to $30
Frames (Once every 12 months)
$0 Copay; $150 allowance; 80% of charge over $150
Up to $75
Single Vision Lenses (Once every 12 months)
$15 Copay
Up to $25
$0 Copay; $150 allowance; plus balance over $150
Up to $120
Or
Contacts (Once every 12 months)
And now it’s time for the breakdown . . .
Here’s an example of what you might pay for a pair of glasses vs. what you’d pay without vision coverage.
So, let’s say you get an eye exam and choose a frame that costs $163 with single vision lenses that have
UV and scratch protection. Now let’s see the difference . . .
90%
SAVINGS
with us
With Us
Without Insurance**
Exam
Exam
$106
Frame
$163
Lens
$78
$0 Copay
Frame $163
-$150 allowance
$13
-$2.60 (20% discount off balance)
$10.40
Lens
$15 Copay
$15 UV treatment add-on
Total
$23 UV treatment add-on
+$0 Scratch coating add-on
+$25 Scratch coating add-on
$30
$126
$40.40
Total
$395
Benefits are not provided from services or materials arising from: 1) Orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; 2)
Medical and/or surgical treatment of the eye, eyes or supporting structures; 3) Any eye or Vision Examination, or any corrective eyewear required by a Policyholder as a condition of
employment; Safety eyewear; 4) Services provided as a result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program whether
federal, state or subdivisions thereof; 5) Plano (non-prescription) lenses and/or contact lenses; 6) Non-prescription sunglasses; 7) Two pair of glasses in lieu of bifocals; 8) Services or
materials provided by any other group benefit plan providing vision care 9) Services rendered after the date an Insured Person ceases to be covered under the Policy, except when
Vision Materials ordered before coverage ended are delivered, and the services rendered to the Insured Person are within 31 days from the date of such order. 10) Lost or broken lenses,
frames, glasses, or contact lenses will not be replaced except in the next Benefit Frequency when Vision Materials would next become available. Benefits may not be combined with any
discount, promotional offering, or other group benefit plans. Standard/Premium Progressive lens not covered-fund as a Bifocal lens. Standard Progressive lens covered-fund Premium
Progressive as a Standard. Premium progressives and premium anti-reflective designations are subject to annual review by EyeMed’s Medical Director and are subject to change based on
market conditions. Fixed pricing is reflective of brands at the listed product level. All providers are not required to carry all brands at all levels. Underwritten by Combined Insurance Company of
America, 5050 Broadway, Chicago, IL 60640, except in New York. CICA Form # VN P63007 0801. This is a snapshot of your benefits. The Certificate of Insurance is on file with your employer.
Benefit allowance provides no remaining balance for future use within the same benefit year. **Based on industry averages.